There is no skill in manual therapy…?

I’m guessing if you are reading this then you are probably a manual therapist, and probably pissed off with the title of my blog that’s just called into question your skill, your training and your experience! But before you ‘blow a fuse‘ and head down to the comments section, please hear me out and continue to read on a little further!

So a few weeks ago, just for a change, I posted a controversial tweet that said…

It had a mixed response, some agreeing, some disagreeing, so I thought I would expand on this a bit more and explain why I think that there is NO ‘technical’ skill needed to apply ANY manual therapy.

Anyone can do manual therapy

I believe anyone can ‘do’ manual therapy well, without any formal training, without any great experience, without any expensive post graduate courses and exams, and get just as good, if not better results than so called highly skilled professionals.

In fact know it!

This is purely anecdotal, but I’ve had an ongoing neck issue for years now, that grumbles now and then and is often aggravated by spending too long on laptops blogging or tweeting. 

Now I’ve sought the help of many professional therapists over the years for this, but the best ‘treatment’ I get without a shadow of a doubt are my wife’s neck massages (that’s when I can convince her to give me one) and she isn’t a trained manual therapist, in fact she doesn’t even work in the healthcare industry.

And I’m not alone, I hear of many others who say similar, that a partner, a friend or an ‘acquaintance’ who isn’t trained in manual therapy gives them a great back rub, head massage or even clicks something now and then that hits the spot and feels ooooh sooooo good.

It’s this, amongst other things that I will get on to, that got me thinking, how is this possible? How is it that my wife makes my neck feel so much better, compared to a £50+ per hour highly trained professional?

Well many argue that this example isn’t a fair comparison, that there are many other factors that a professional therapist just cannot reproduce, such as higher levels of familiarity, relaxation, playfulness etc. But that is exactly my point. It is these non specific factors and not the technical application of manual therapy that makes it more effective, and this is EXACTLY why it raises some BIG questions around the belief many therapists have about technical skill with all manual therapy.

Human touch can be powerful

Many mistake my constant skeptical critique of manual therapy as me saying it doesn’t work or it doesn’t have a role. That’s just not true, and a false dichomtomy and pisses me off hugely, please stop it. 

Yes in my opinion manual therapy is over hyped, over used, and surrounded by heaps of pseudoscience, marketing and gimmicks. But there is no denying that human touch can be, and is a very powerful tool. There is also evidence that explains how touch is part of our evolutionary development as mammals, and how it helps us bond and form social groups, relieves pain, both physical and emotional. Simply put touch is soothing, calming and relaxing (source, source).

But what I am highly critical and skeptical about is those who try to make this process of simple, caring, soothing touch over complicated, over technical and over hyped in its application!

My experience

Now before I go any further, let me tell you my story with manual therapy just in case you mistake my opinions as being ill-informed or inexperienced. You could not be further from the truth.

My training and education in manual therapy extends well over a decade and is extensive, wide ranging and unfortunately for me been really, really bloody expensive. I have completed all of the well recognised post grad courses in manual therapy, and a few of the other not so well recognised ones. I have been taught by some of the worlds most influential figures in this field. I’ve gained qualifications, sat exams and jumped through the hoops of observed assessments and viva’s. Some would class me as ‘skilled’ manual therapist, but as I’m arguing against this exact fact I won’t!

What is manual therapy?

Manual therapy means different things to different people. When I say manual therapy I mean anything that involves one person being touched, pressed, rubbed, poked, pulled or cracked by another with a hand, finger, foot, elbow, knee or even some tool or device in a so-called ‘therapeutic’ fashion.

Manual therapy exists under bewildering array of names, some well-known ones like massage, manipulation and mobilisation. Sometimes they have more complex and ‘scientific’ sounding names like effleurage, petrissage, myofascial release or deep transverse frictions. Some have more exotic and glamorous titles like Tunia, Graston, Active Release Techniques, and then there are those named after their influential creator such as Rolfing, Maitland or Bowen.

Although all of these techniques have different methods of rubbing, pressing, pulling or poking, the one thing they all have in common is they all have a course or series of courses to attend, and a test to pass to show you have acquired the ‘skills’. Some of these courses last a few days, others longer, with the costs ranging from a few hundred quid to thousands of pounds, dollars or euros. I dread to think the total cost of my manual therapy training but I guess its over £5000.

Now if you do have cash to burn, and you really would like some help in deciding which manual therapy course to take next, I’ve done a helpful little flow chart below to help you out…

Anyway, each technique/method is thought to achieve its effects via different mechanisms, and they all vary in their thinking and explanations how this is achieved. However, one thing that is the same with all of these methods, is they are all based around the notion of changing a structures position, length or freedom to move. Be it a muscle, tendon, ligament, fascia or a joint. They all attribute the positive effects of their manual therapy technique to these factors and ignore the effects of touch on the central and peripheral nervous system, as well as ignoring the host of other non specific factors that manual therapy achieves.

And more annoyingly they all think that their method is far superior than the other methods, with such an air of snobbery and self-imposed hierarchy it is one of the reasons I dislike the manual therapy industry and its guru’s so much.

Frustration

But the other reason why I dislike the manual therapy profession so much, and why I am being highly critical of it, is that after spending many thousands of pounds, and many years of my time, being taught and lead to believe that manual therapy is a big powerful tool that can help ‘fix’ or ‘cure’ people in pain. I have come to realise that this just isn’t the case. Manual therapy is not as powerful or useful as many claim, it’s certainly not as specific and lets get to the crux of my blog… there is NO technical skill needed!

This annoys me, frustrates me, and pisses me off immensely. Firstly because I feel cheated, mislead and lied to, and secondly because I see that it continues to happen right now, all the time, to many other therapists. In fact the myths and misconceptions about manual therapy seem to be growing stronger and more fanciful as time goes on, and nothing seems to be changing.

A slow realisation

I came to realise that manual therapy isn’t all I’ve been taught or lead to believe slowly, and that’s even with my own strong natural skeptical side always whispering in my ear “this just ain’t right mate”

I began to notice that the results of all these manual therapy methods were highly variable, despite my extensive training, despite my detailed assessment and skilled application. I also began to notice that when I didn’t do the technique exactly the way I was supposed to it didn’t change the outcome or result one bit, some got better, some didn’t as usual.

So I began to ‘experiment’ more and more, and began to realise more and more that actually it didn’t matter how I poked, prodded or rubbed someone. Eventually, I stopped all the ritualistic, pseudo scientific assessments that I had been taught, such as looking for, and feeling for a joints position or movement, poking soft tissues feeling for knots, bands, spasms etc.

Instead I started to talk and listen to my patients more, much more. I spent time finding out what their beliefs, experiences and more importantly their expectations and understanding of manual therapy! I found that by asking patients these questions it allowed me to gage IF manual therapy was suitable, appropriate and even if it is wanted by a patient, not automatically assumed it is based on my assessment.

Research, evidence and an awaking

I then began to read more, a lot more. I looked at the ‘evidence’ with an increasingly critical mind, looking at the method and result sections of the research papers first, even brushing up on my statistics. What I found was most of the research is flawed with methodological design issues and biases so big they dwarfed my own.

I then read more and found therapists and researchers who believed in an open, honest and rationale view of manual therapy, taking into accout all the variable and factors that cause effects with manual therapy, not just the physcial and biomechanical. Researchers such as Bialosky, Zusmann, Gifford and Lederman. I read more and more around pain and neuroscience, human behaviour, and psychology from experts such as Sapolsky, Quintner, Shacklock, Moseley, Butler and many others.

I found other therapists online who were also disenchanted with the biomechanical myths around manual therapy, and they pointed me towards even more research and more evidence, making me question everything I had been taught.

I learnt you can’t increase blood flow, break down scar tissue, melt adhesions, ‘release’ muscle or lengthen fascia (Shoemaker 1995, Chaudhry 2008, Chaudhry 2007, Schleip 2003, Threlkeld 1992)

I learnt that stretching a tissue in a certain way, for a certain amount of time just doesn’t effect it’s structure in any signficant way (Solomonow 2007, Weppler 2010, Katalinic 2011 Konard 2014)

I learnt that you don’t need to mobilise or manipulate a joint in a specific direction, based on a pattern of pain or specific assessment of movement and joint feel (Chiradejnant 2003, Aquino 2009, Schomacher 2009, Nyberg 2013)

I learnt that palpation of muscles, joints, trigger points are all very unreliable and leads therapists to misdiagnose often and direct treatment down wrong and ineffective pathways. (a blog I have done on palpation with all the supporting evidence is here.)

I learnt that when all the different methods and techniques of manual therapy are examined through the process of systematic reviews and meta analysis, most of the research is poor and even the good research shows that it doesn’t do much (Menke 2014, Kumar 2014, Artus 2010, Kent 2005)

It has been a revelation, an awaking. A slow and gradual opening of my eyes, but they are wide open now, so I can now confidently say…

There is NO skill in manual therapy, and it really doesn’t matter how you do it.

Caveats

Now having said all that there are a some caveats that a manual therapist does needs skill in.

Although the risk of causing any structural damage to connective tissues is small, there are some high velocity techniques that do potentially have a risk of harm and potentially life threatening injuries.

High velocity manipulations, end of range traction and even joint mobilisations to the upper neck have been documented to cause some rare but serious injury’s and in some worst case scenarios, death (source)! So it goes without saying that a full awareness and identification of those at risk as well as ensuring the application of the techniques is done safely is a must. Although I argue that if there is such a risk and minimal benefit with these methods why even do them at all (source).

Another skill all manual therapists need is the ability to identify and recognise those presenting with serious pathology masquerading as musculoskeletal pain.

Lastly but most importantly, all manual therapist needs skill in interaction!

Being able to connect, relax, reassure and calm people is a ‘skill’ not to be taken for granted. It’s this skill combined with simple, confident, comfortable handling skills that I truly believe distinguishes a great manual therapist from a good one, not any Jedi abilities, qualifications or recent courses they have attended.

Fighting against the tide!

So there you go, my explanation of why I think there is NO technical skill in manual therapy. Even if we could assess accurately and reliably a stiff joint, a muscle knot or some other structural fault, all the effects of manual therapy are not structural, so it really doesnt matter how you or where you press or poke someone, it only matters to the patient and so they need to tell and guide you as what and where to go.

Manual therapy’s effects are due to a host of non specific psychological and neurological factors that do require some skill in acquiring and some understanding and awareness of.

So this is my own story of my desire and passion to learn about manual therapy followed by my disillusion and disenchantment by the nonsense and rubbish surrounding it. I now find myself (unexpectedly) as a cynical, skeptical and often misunderstood critique of manual therapy for which I’m hoping this blog will provide some clarity of where I am coming from.

Let me also state once more that my aim is not to put people completely off manual therapy nor negate or belittle the non specific effects of human touch, or say that manual therapy doesn’t have a role or place in rehab.

Instead my aim is to try and debunk the biased, flawed and general crap that surrounds it, and to be a thorn in the side for the few unscrupulous manual therapy ‘guru’s’ pedalling their courses and pushing their fanciful teachings and wild claims for profit rather than helping patients.

Unfortunately, I seem to be doing this more and more as the greedy and at times immoral, manual therapy industry continues to grow into an ugly profit driven commercial business, motivated more by money than outcomes, feeding off patients in pain and with injury, feeding off well meaning therapists wanting to help who get sucked in to all the courses, workshops, manuals, books, DVDs, and seminars.

So please expect to hear me rant, moan and wail on this subject for while longer.

As always thanks for reading

Adam

110 thoughts on “There is no skill in manual therapy…?

  1. Nice read. My apologies, VERY, VERY NICE READ. Thank you God for your critical, excellent mind.

    Interaction more than intervention! 👍👍

    Nathan
    Manila, Philippines

  2. Couldn’t agree more. I’ve been at the game for 40 years. Taken courses from many practitioners and angles dating back to “Fat Jack” Cyriax himself. I have come to view manual therapy as more of an art than a skill. I had the great honor to have the late Dick Erhard as a mentor and friend. Privately he could be quite cynical about manual therapy, but there was no denying the man’s genius for evaluating the patient and determining what it would take to improve that patient’s situation, and it often came down to a couple of simple exercises. His gift was knowing the patient, something you can’t teach in a post-grad manipulation course. The same can be said for the family doc I knew as a kid whose familiar voice, concern and assurance were more effective treatments than anything he carried in that little black bag.

    I will continue to seek to develop any skill that I think may help my patient. That pursuit can, at least, sharpen my thought processes. At the same time I will remember that my most gratifying results come from developing a relationship with my patient and letting him dictate the treatment. As you said….interaction, not intervention.

  3. I believe the problem lies in having the right perspective or medical model that increases the accuracy of choosing the right intervention for the patient’s specific problem. When all you own is a hammer… everything looks like a nail. I can train a non-professional in how to provide some of the interventions I use. I can even have them perform the intervention on a patient and results are generally positive (with pre-test and post-test findings). But, I am not ready to conclude that some interventions do not require high level of skill to execute properly.

    My question for you, whoever-thinks-they-are-a-manual-therapist, is: Do your interventions have immediate effects of markedly increased ROM, increased force-generation capacity, improved fluidity of movement, and increased speed, along with long-term pain relief in the focused area where you applied the manual therapy intervention?

    If your manual therapy interventions do not fix the underlying problem, then it either means you are doing something wrong (poor selection of intervention and/or poor execution) or that manual therapy is not the correct treatment of choice. You may not be getting to the problem in a way that can correct it. It is just as possible that another intervention that was properly targeted and executed would correct the problem immediately.

    Think about the example of nurse-maids elbow. The elbow is dislocated and then 2-minutes after the proper manual therapy intervention the child is happy again, ROM is restored, etc. Shall we do a study of the effectiveness of relocating a nurse-maids elbow? Do we need to? Or shall we just continue our clinical practice of manual therapy, where it absolutely takes skill to interpret the findings, select the intervention, and execute?

    • Hi Howard

      Thanks for your comments, you make some interesting points

      First you state that if we dont get immediate results after manual therapy then our technique or selection was wrong, i may agree that selection of manual therapy may be wrong here in a hands on hands off kind of way, we all have had those patients we think manual therapy will help only to touch them and feel them stiffen tense up in fear pain etc and despite or best efforts they dont respond

      But immediate effects due to the direction of push pull poke or press is something i do not agree with, as long as the MT is comfortable and the patient feels and gives feedback as such then it doesn’t matter, just because I think a right unilateral L5 Grade 3 mob is needed doesn’t mean diddly squat if the patient doesn’t feel its right and thats my point re skill in manual therapy the skill is in communicating and interacting with your patient not the intervention

      Lastly you use a an example nurse maids elbow, which is a gross traumatic dislocation that needs correcting just as a dislocated GHJ does this is not the same as manual therapy for a low back pain of stiff neck

      Regards

      Adam

  4. Is it possible that there is a better way than what we “know” now as a whole group? Is it possible that skill is required to execute the specific intervention that is needed for the individual? I really believe that manual therapy will either immediately correct the problem that is specifically addressed or the problem cannot be fixed by manual therapy. I see immediate solutions every day. It does take a high level of skill and a knowledge base that is not widely known. And the reality is that the solutions are as simple as understanding anatomy and neuroscience and how both can be corrected when in a dysfunctional state. Fascia can be immediately corrected and faulty muscle spindles that restrict normal ROM can be reset. But, it takes a paradigm shift that many are not willing to make. Again, I disagree with your hypothesis.

  5. I have one LARGE issue with this blog. A sneaky snide comment thrown in which sets manual therapists back to the dark ages. It’s comments like “if you pay a little extra” that hurt the profession. And arrogant guys like you seem to be the worst for it. I stopped reading after that comment. Sad.

    • Im sorry you think me arrogant from one light hearted quip, I think you are being a little unfair and would ask that perhaps you get to know me before making such offensive ad hom comments, and also maybe see the light hearted nature of the comment

      • I would have liked the same treatment from you when you bashed my presentations at the world golf fitness summit without knowing anything about it or me. . I am in agreement w the premis that there is much we don’t know and we need to be citizen scientist and learn for ourselves in a safe collaborativeffort. Look me up … We are not that far off.
        Marcwahl.com

  6. Nothing light hearted about posting a comment about the stigma of manual therapy that manual therapists have been trying to overcome for decades. Seriously, get a grip.

      • Hi Adam

        I agree about your comments on professionals that think they are god’s gift about manual therapy. I currently work in New Zealand and although a pioneer of his time McKenzie is still the gold standard over here. I mean c’mon people, really??

        I laugh at the comments other professionals make (although to be fair it is individuals such as yourself that do and can destroy their bread and butter), this however to me shows a lack of insight into keeping abreast of EBP and considering the alternative methods such as, improving your people skills?

        I was recently ostracized by a student chiropractor for claiming that I was taught manipulations by a chiropractor that they were not true manipulations because I am a physiotherapist, what an utter load of big fat BS!

        Really enjoying your rants it makes for excellent comedy, it’s great that some people are narrow-minded as it makes it all the more entertaining for me when a rant exchange commences!

  7. Hey Adam,

    Very, very, very interesting blog post. I am one of those guys who has spent quite a lot of money in courses and I am still waiting for an explanation that convince me about the way some techniques are supposed to work.
    I would have liked to be the one writing about this topic, although it sounds much better in proper English. I am Spanish and my English sounds awkward sometimes!!

    Many thanks for the post

  8. My sentiments exactly. I’m in the first year of my career and I see and read so much bullshit that I actually became quite depressed for a while. Then I thought…well everyone feels good when they get off my table. They feel relaxed and a bit more limber for a while and that is enough for me. There aren’t many things these days except alcohol, drugs and sex that make you feel a bit more cheery and relaxed. I charge half of what others charge because I think massage rates are FAR too high and i don’t want people to think of it as a luxury for wealthier people. I read a lot, watch technique videos and talk to more experienced therapists.
    Thank you for your simple, no bullshit or jumbo jumbo views!

  9. Hi Adam,
    I am (partly) glad I came accross this article, it certainly insights a lot of thought and discussion as is represented throughout the comments!!
    I could go into details on my views however much of these have been discussed previously and I found myself agreeing in parts with both sides of the discussion/argument while reading through the comments, like most people I guess.
    The point I will make however is that justifying parts of this discussion by evidence seems a tad worthless due to the fact that for every paper claiming manual therapy ‘doesn’t do much’ there is another representing its benefit in treating numerous musculo-skeletal conditions http://www.sciencedirect.com/science/article/pii/S1356689X15001745. Admittedly I wasn’t keen on spending $35.95 to view the whole paper to then find the likely numerous floors in the evidence but this is no different to most other studies such as Shoemaker 1995 who concluded no impact on tissue bloodflow following a study on just 10 persons.
    I use manual therapy with every patient I can (those without contraindications to it) and get the right results (most of the time). I do also use re-assurance, activity modification and exercise, arguably it may be those things which impact on a patients symptoms, although I am far from convinced, but more importantly in my view I do doubt my patients would be half as happy if they left their appointment following a chat and an exercise sheet.
    I understand you are not rubbishing manual therapy completely, however some of your points are less agreeable than others.
    Great effort in getting such a discussion going, it’s been a good read and a good opportunity to look into the research a bit more.

    • If your manual therapy techniques are not the primary cause of the improvements then ethically you should not be applying the techniques. If the chat and exercise sheet is improving their condition then you are actually worsening their condition by letting them think that its the manual therapy. Persisting with innefective or minimally effective treatments is a reason why health and medicine has not been able to reduce the prevalence and impact of musculoskeletal pain syndromes despite massive advances in medical care as a whole.

  10. Great post….I have been practicing “manual therapies” for 21 years now, my training is primarily Craniosacral Therapy to advanced level, whatever that means, biodynamic cranial, visceral manipulation and some traditional osteopathy. I also have a allopathic medical background.

    What I learned from all that training was anatomy, distinctions and frames of reference, but where I learned the most was in practice. At this point, my hands are extremely sensitive, and I can feel systemic, inter-related patterns contributing to a person’s symptoms, fascially, neurologically, vascularly and lymphatically.

    I’ve witnessed some seeming miracles with clients, even having several who were able to cancel surgeries after one session. Assessing and treating this stuff does take SOME skill-knowledge of anatomy, the ability to get quiet mentally to focus on and perceive extremely subtle tissue interrelational dynamics, mechanics and releases, a caring heart and true love for the patient to be able to be present with them, create a safe space and listen to them, like you said, and truly wish to serve their highest good.

    Did I need to pay for any of this knowledge? Looking back, I would say no because where I learned the most was in hundreds of hours of client sessions as well as studying anatomy and neurophysiological dynamics on my own. Truly. Gotta love “google university.”

    So I really have to agree with you. Just like healers of old had a “gift” and a caring heart, with a little motivation and perseverance, anyone who truly wants to can become an excellent manual therapist. My two cents! God bless.

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